evaluation of posterior hip pain · anterior (groin pain) typically intra -articular pathology such...
TRANSCRIPT
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Evaluation of Posterior Hip Pain
Anthony J. Ferretti, D.O., MHSA
Hip Pain in the AdultVarious etiologies:
● Traumatic● Infectious● Neurovascular● Degenerative● Congenital● Pathologic
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Hip Pain●Complex interaction of both intra-articular and extra-articular
pathology causing pain. Origins may be:○Capsulolabral○Osseous○Neurovascular○Musculotendinous○Pathology involving the lumbar spine
Pain patterns●Hip pain patterns:○Anterior (groin pain) typically intra-articular pathology such as osteoarthritis○ Lateral (trochanteric pain) typically extra-articular pathology such as trochanteric
bursitis○Posterior (buttock pain) typically ???
■ Intra-capsular pathology■ Extra-capsular pathology■ Emanating from the lumbar spine or SI joint
●Involves a complex interaction between anatomic structures, ROM, and neuromuscular activity
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Main differential of posterior hip pain
● Various types of impingement● Hip-spine syndrome● Hamstring syndrome or
proximal hamstring tendinitis● Sciatic nerve entrapment● Pudendal nerve entrapment● Deep gluteal syndrome
● Piriformis syndrome● SI joint pain● Referred pain from the lumbar
spine● GU disorders● Labral tears● Osteoarthritis● Inflammatory arthritis
History●Understanding the origin of hip pain is key to identifying the pathology
and which patients would benefit from a conservative vs a surgical approach to treatment
●Diagnosis involves a complete history, physical exam, and any necessary imaging
●Every hip exam should include a back exam to rule out lumbar spine pathology○Any pathology that limits hip extension may emanate from the lumbar spine…
● A proper history should lead you to the diagnosis
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History taking●Should include:○Chief concern documented○Date of onset○Presence or absence of trauma○ Localization of pain○Mechanism of injury○Referred pain patterns○ Severity of pain○Aggravating or Alleviating factors
○ Prior surgeries and hardware present
○ Treatments tried thus far
HistorySometimes a history will point you in the right direction:
● If severe hip pain with history of chronic steroid use or alcohol abuse - think osteonecrosis of the hip
● If elderly or frail patient with osteoporosis - think fragility fracture
● If inability to bear weight with a mechanism of injury - think traumatic fracture
● If pain or paresthesias that radiate down the leg past the knee - think lumbar spine pathology
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History
Always document sports or hobbies patient is involved in:
● Female ballet dancers or gymnasts can experience hip laxity and instability
● Recent increases in activity may suggest a stress fracture
● Many athletes can suffer from a wide range of hip pathology
Physical exam●Posterior hip pain typically occurs from extra-articular sources and
causes a more global pain distribution○ Intra-articular pathology typically radiates to the anterior or medial thigh due to the
femoral or obturator nerves○Difference between hip pain and “C sign”
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Physical exam●Step 1 – rule out lumbar spine
pathology:○Range of motion○ Increasing pain with extended or
flexed posture○Radiating or radicular pain patterns○Dermatomal sensory loss○ Strength testing○ Straight leg raise test
○ Reflexes
Physical Exam●Step 2 – Determine the location of pain:○ TTP over the greater trochanter suggests trochanteric bursitis○ TTP over the ischial tuberosity (gluteal crease) suggests ischial bursitis○ TTP medial to the ischial tuberosity suggests pudendal nerve entrapment○ TTP posterior or lateral to the ischial tuberosity suggests hamstring tendinitis○ TTP over the SI joint suggests sacroiliitis
Documenting the patient’s localization of the pain is a key finding!
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Physical Exam●Step 3 – Assess gait pattern:○Antalgic gait○ Trendelenburg sign○Wide based gait (myelopathy)○ Long stride walking test○Use of assistive devices (and which
hand they use it in)○Asymmetric shoe wear
Physical exam●Step 4 – Assess ROM, strength,
and sensation○ Long tract signs - Babinski and clonus○ Tension signs○Don’t forget to rule out claudication
symptoms
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Physical Exam●Step 5 – Special testing○ Log roll○ FABER and FADIR tests for
impingement○Hamstring active test○ Straight leg raise test○ SI joint tests – Gaenslen, distraction,
compression, thigh thrust
Physical Exam
Step 6 - Think outside the box.
If no obvious source of hip pain, then think of spine or SI joint:
● Neurovascular exam● Pain worsened with lumbar
flexion or extension?● SI joint tests ● Other source of symptoms -
gynecologic or urologic
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More common posterior hip pathology
● Lumbar spine pathology○ With or without radiculopathy
● SI joint pain
● Piriformis syndrome
● Proximal hamstring pathology
● Impingement
Impingement
● When two structures come into contact with each other and cause pain
● Various etiologies of impingement:● Sciatic nerve can rub against the greater trochanter as the hip
moves into deep flexion, abduction, and external rotation● A prominent AIIS or part of the ischium can come into contact
with the lesser trochanter or proximal femur and cause pain● Various musculotendinous structures can be impinged between
bony structures with extremes of motion
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Impingement testing
Anterior vs Posterior impingement:
Deep gluteal syndrome
● A syndrome in which the sciatic nerve is entrapped between various structures in the deep gluteal space
● Often presents with a traumatic mechanism of injury● Pain with prolonged sitting in a balanced position; frequently
offloads the affected side during sitting● May present with sciatica symptoms
○ Pain and/or paresthesias that radiate down the posterior thigh to the knee
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Pudendal nerve entrapment
● TTP medial to the ischial tuberosity
● Worsened with sitting, partially relieved with standing and walking
● May present with pain or paresthesias in the perineum
● Alleviated when sitting or a toilet or pillow
○ patients who ride bicycles for prolonged periods can be affected
● Damage to this nerve may represent a broader syndrome including pelvic floor insufficiency
or incontinence
SI Joint pathology
● TTP that is medial and inferior to the PSIS likely emanates from the SI joint and has high sensitivity
● Various etiologies:1. Traumatic2. Degenerative3. Inflammatory4. Hypermobility related to pregnancy5. Infection
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SI Joint pain
Testing:
Proximal hamstring tendinitis
● TTP localized lateral or posterior to the ischial tuberosity● May have pain or weakness with resisted hip extension and knee
flexion
● Hamstring syndrome = irritation of the sciatic nerve due to inflammation and scar tissue associated with hamstring pathology○ Can present with sciatica symptoms
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Piriformis syndrome
● Presents with buttock pain or pain in a sciatic nerve distribution
● Pain is exacerbated by forward bending or heavy lifting
● Gluteal atrophy may be present● Diagnosis of exclusion
Frieberg test ->
Imaging
1. Xrays
○ Good initial imaging modality○ Evidence rating of C by AAFP
2. CT
○ Rarely needed except in surgical planning
3. MRI
○ High sensitivity and specificity○ Can be used to rule out occult fracture or lumbar spine pathology○ Can demonstrate nerve entrapment
4. Ultrasound
○ Becoming more common to diagnose musculoskeletal pathology, especially with more superficial structures
○ Diagnosis is operator dependent
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Treatment options
● Pain medication■ Tylenol, NSAIDs, or trial of corticosteroids
● Physical therapy■ Home exercises vs formal therapy■ Mackenzie exercise program for low back pain
● Rest and temporary cessation of aggravating activity● Other modalities
■ Heat, ice, stretching, OMT, accupuncture, iontophoresis● Diagnostic lidocaine injections
■ Especially helpful for diagnosing SI joint pain
If no relief, then referral to an Orthopedist is recommended
Questions?
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References1. Battaglia, P., D’Angelo, K., and Kettner, N. (2016). Posterior, Lateral, and Anterior hip pain due to musculoskeletal origin: A narrative literature review of
history, physical examination, and diagnostic imaging. Journal of Chiropractic Medicine, 15(4): 281-93.
1. Frank, R. M., Slabaugh, M. A., Grumet, R. C., Virkus, W. W., Bush-Joseph, C. A., & Nho, S. J. (2010). Posterior Hip Pain in an Athletic Population: Differential Diagnosis and Treatment Options. Sports Health: A Multidisciplinary Approach, 2(3), 237-246. doi:10.1177/1941738110366000.
1. Gómez-Hoyos, J., Martin, R. L., & Martin, H. D. (2018). Current Concepts Review. Journal of the American Academy of Orthopaedic Surgeons, 26(17), 597-609. doi:10.5435/jaaos-d-15-00629.
1. Wilson, J., Furukawa, M. (2014). Evaluation of the Patient with Hip Pain. American Family Physician, 89(1): 27-34.